Music Education Hub Mentoring Programme 2017/18

Mentor Registration FormConfidential

1 Name

2 Job Title

3 Organisation

4 Contact details:

Address

Telephone Mobile E-mail

Questions 5–8 will enable us to carry out equal opportunities monitoring.

5 Are you Male Female

6 AgeUnder 31 31–45 46–60 61–70

7 What would you describe as your cultural/racial origin?

8 Do you consider yourself to be disabled? Yes No

If yes, do you have any specific requirements?

9 What are your current main areas of responsibility?

10 What are your specialist areas of skills and experience?

11 Do you have any experience of being a mentor or coach? If yes, please describe:

12 When are you available for meetings? Day Late afternoon Evening

13 How often would you be able to meet with a mentee? (eg once a month)

14 Are you able to meet undisturbed with a mentee at your workplace?

Yes No

15 How far could you travel to meet with a mentee, if necessary on occasion?

16 Would you be happy to mentor over the telephone on some occasions if geography required?

17 Do you have any preference for your mentee in terms of their area of work, seniority etc?

18 What are your reasons for volunteering for this programme? (Tick all that apply)

Personal development Management skills development Networking/profile

Enjoyment/interest Increased confidence Other, please specify below:

19 What are your outside interests?

20 Is there any other information about yourself that you feel may be relevant?

Signature Date

If you return this form electronically from your own email address, then the signature will be presumed to be present.

Data Protection Act 1998: We are required by law to obtain your ‘informed consent’ to hold your personal details on our databases. Vivienne Tyler trading as Business in the Arts holds a database of individuals and organisations with whom it works. Your information is entered on to our database and it will be used for internal administration, monitoring and to contact you regarding the Mentoring programme. Your details will only ever be passed to an individual that you have consented to meet with or work with through the programme.

Do you consent to your personal details being stored on the database?Yes No

Please return this form along with your CV/career summary and Job Description by 7 August 2017 to:

Vivienne Tyler

Email:

Telephone: 07903 369 896